Recently, I retook Advanced Trauma Life Support. I had been an instructor in the past, but lapsed during my own medical treatment. But, now, back in the trenches, I needed to redo my certification. Since it is geared toward standardizing trauma care, the issue of mass casualties is addressed. Even with a modern trauma center, a natural or man-made disaster could overwhelm the locally available resources. Traditionally, this was more of a problem for the military, and it was in that setting, during the Napoleonic wars, that the term "triage" originated.
Triage consists in dividing patients into three categories--those with unsalvageable injuries, who will die regardless of care; those for whom treatment will make the difference; and those with minor injuries who will survive regardless of care. Clearly, in the mass casualty setting, attention is directed toward the middle group, with minimal resources directed toward the other two.
Modern healthcare has become so costly, that a society must decide how to allocate resources. Clearly, an extremely old and debilitated patient will not have a long survival with an aggressive cancer. So, perhaps care should be directed to palliation rather than attempt at cure. This might be kindest, as well as most cost effective.
Similarly, those with minor self-limited issues might be best treated with "watchful waiting" and reassurance. Again, what is best for society is also best for the patient.
The middle group is where the resources should be directed. These are the patients for whom more aggressive treatment will make a difference in outcome. Most infectious diseases have a low cost to benefit ratio, and their treatment is also beneficial for society. Cancer treatment is often costly, but is valuable to the patient and to society if there will be a reasonable length of survival with good quality of life. Recently, I reflected on the dozen or so of my friends who are back working full time after cancer treatment. For us, it was definitely worth it. But, I don't know if I would have wanted to go through it at age 90.
This sort of allocation is gradually becoming more accepted, as people are not wanting heroics as much near the end of life. But, still, nearly half of our health care expenditures are in the last month of life. If we, physicians, could do better at prognosticating which of the groups a patient would fall into, we would be better able to discuss potential outcomes, and guide patients and their families through end of life decisions. I am convinced that this lead to better outcomes for both the individual and society.
Triage consists in dividing patients into three categories--those with unsalvageable injuries, who will die regardless of care; those for whom treatment will make the difference; and those with minor injuries who will survive regardless of care. Clearly, in the mass casualty setting, attention is directed toward the middle group, with minimal resources directed toward the other two.
Modern healthcare has become so costly, that a society must decide how to allocate resources. Clearly, an extremely old and debilitated patient will not have a long survival with an aggressive cancer. So, perhaps care should be directed to palliation rather than attempt at cure. This might be kindest, as well as most cost effective.
Similarly, those with minor self-limited issues might be best treated with "watchful waiting" and reassurance. Again, what is best for society is also best for the patient.
The middle group is where the resources should be directed. These are the patients for whom more aggressive treatment will make a difference in outcome. Most infectious diseases have a low cost to benefit ratio, and their treatment is also beneficial for society. Cancer treatment is often costly, but is valuable to the patient and to society if there will be a reasonable length of survival with good quality of life. Recently, I reflected on the dozen or so of my friends who are back working full time after cancer treatment. For us, it was definitely worth it. But, I don't know if I would have wanted to go through it at age 90.
This sort of allocation is gradually becoming more accepted, as people are not wanting heroics as much near the end of life. But, still, nearly half of our health care expenditures are in the last month of life. If we, physicians, could do better at prognosticating which of the groups a patient would fall into, we would be better able to discuss potential outcomes, and guide patients and their families through end of life decisions. I am convinced that this lead to better outcomes for both the individual and society.
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